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The Medical Coder is responsible for translating medical diagnoses, procedures, and services into standardized codes for billing and documentation purposes. This role ensures accuracy and compliance with coding guidelines and regulations.
Key Responsibilities
Corresponding Key Activities performed by the role
Managerial
Technical
Review and analyse patient records to identify relevant diagnoses and procedures.
Assign accurate ICD, CPT, and HCPCS codes based on clinical documentation.
Ensure coding compliance with regulatory standards, payer requirements, and hospital policies.
Collaborate with physicians and healthcare providers to clarify diagnoses or treatments as needed.
Assist in resolving coding discrepancies or claim denials with the billing department.
Maintain confidentiality and integrity of patient records.
Keep updated with changes in coding standards, healthcare regulations, and industry best practices.
Quality and Safety
Promoting and maintaining quality in all services and ensure continuous quality improvement measures are in place. Conduct method evaluation/ development as per standard policies and procedures
Complying with all safety and quality control programs and procedures as applicable
Complying with applicable precautions for environmental safety, infection control, using a series of interventions that minimize or prevent cross infections
Ensuring that safety procedures and quality assurance tests are maintained within all sections
Comply and support clinical audit processes within the service and report on these as agreed
Communicating in a professional and courteous manner with patients, family and other medical personnel as necessary to obtain information for laboratory records, explain procedures, clarify orders and communicate status.
Continuous Education
Participating in education sessions for department staff, doctors and nurses on the safe and secure handling of equipment, i.e teaching, induction, peer review, case studies, and clinical presentations
Participating in department programs/ committees, various hospital committees, and staff meeting (when requested)
Participating in the orientation and training of new employees
Maintaining professional knowledge by attending lectures, seminars or on-line education sessions
Completing and maintaining all regulatory requirements including licensure and certification and other mandatory training within established time frames.
Occupational Safety and Health Management Systems
Comply with reasonable OSH instructions, policies and safe working procedures
Use of appropriate personal protective equipment and safety systems.
Be familiar with emergency and evacuation procedures
Not wilfully or recklessly endanger anyone’s health and safety
Attend all OSH Trainings, awareness programs and mock drills.
Participates in the OSHMS audits, inspections, ensuring standards are maintained
Prevention and Control of Infection (PCI):
PCI is everyone’s responsibility. All staff are required to read and implement the NMC PCI Policy and Strategy to maintain the highest possible standards of cleanliness at all times, thus reducing the risk of infection in patients, staff and visitors.
Qualification, Licensure, Experience and Special Skills:
Qualifications & licensure
• Certification in medical coding (e.g., CPC, CCS, or equivalent).
• In-depth knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
• Familiarity with medical terminologies, anatomy, and physiology.
• Knowledge in hospital information systems and coding software.
• Strong attention to detail and analytical skills.
• Effective communication skills for interacting with clinical and administrative teams.
Experience required in addition to the Qualifications mentioned above
Specialist Certification
Required: NA
Desired: NA
Additional requirements
IT competencies.
Remarks
(add department specific requirements if any)
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